23 February 2007

Wowie. I leave you people without adult supervision for a couple of days and see what happens in the comments? (I was away, and unexpectedly without internet access -- oh the pain!)

Well, I'm back, and first of all I do want to thank all of those who shared their personal experiences, and also faithful commenter/blogger Scalpel, for his determined responses. Despite our contrasting viewpoints, I suspect we have more shared points of agreement than differences. That may be a by-product of working in the same trenches, and the same frustrations with the particular patient population that tends to show up in the ED. Specifically, I think we agree that the lack of personal responsibility demonstrated by (some of) the patients we see is maddening, and that a carte blanche system such as Medicaid encourages irresponsible utilization. Any policy solution which addresses the uninsured crisis should do so in a manner which ensures that patients do have a direct personal financial incentive to ensure that their health care dollars are spent in a rational manner.

Scalpel makes a couple of other points which I would like to address:

"Plenty of people with insurance don't take care of themselves either."I have heard this many times from many sources, not just Scalpel. It's not totally off-topic, dovetailing with the "personal responsibility" theme, but it's also, well, irrelevant. There's a kind of implication that good health is a result of moral rectitude, and illness is somehow a deserved consequence of the patient's choices. It's a tempting conclusion to draw, given the self-destructive crap both Scalpel and I see every single day. But the counterpoint, a universally observed phenomenon among ER docs, is that the more upstanding a person is, the more likely they are to have some bizarre and lethal diagnosis (I recall the time the Chief of Police came in for a sore throat and I diagnosed him with metastatic laryngeal Ca -- a nonsmoker, of course). The other bizarre corollary is that the "scumbags" are just impossible to kill, it seems. They get drunk and fall off bridges and walk away.

But I digress, which should surprise nobody. The point, I think, is that how well one takes care of oneself should have no bearing on whether an individual is allowed to access the health care system.

"Health care is not a right."This has been gnawed over to a great degree at Gruntdoc and KevinMD with no shortage of passion, and I will not even try to delve the complicated depths of this argument in an off-the-cuff post like this one. I repeat that there is a place for personal responsibility, and my preference as a physician and entrepreneur is to retain elements of the system which allow me to set/negotiate prices and retain a profit incentive. However, I am not willing to embrace any system which simply excludes 20% of the population with a shrug of the shoulders. I like the train of thought proposed by JimII -- the right to life is a fundamental right; therefore health care necessary to sustain life should be considered a fundamental need inseparable from the right to live. Whether you call it a right or an entitlement or just "universal" is a matter of semantics which means nothing to me. Consider it a moral imperative if you will -- design a system which will cover everybody. That is all I care about.

Scalpel does offer one common false choice: "if we try to provide healthcare for all, they may have to settle for "good" healthcare. Not super-excellent top -of-the-line healthcare." This is right up there with the whole "rationing" argument. Yes, it is possible that systems might be implemented which would ration or diminish the quality of care (see: Canada, UK/NHS). However, these are not obligatory consequences of universal coverage. Much of the ailments which plague the NHS and Canada's Medicare derive from underfunding. Since we're already paying top-dollar for our system, a system which simply preserves expenditures at current relative levels (with appropriate flexibility) should prevent the woes of rationing. As long as we are willing to pay for it -- through payroll, or taxes, or premiums -- there is no reason we cannot continue to enjoy the current quality of care that exists.

By the way, I am even open to a two-tiered system, in which the wealthy can purchase better or preferential access to care, if it is the cost of entry into universal coverage.

"Uninsured care can be handled at the state level with federal assistance. Further federalization of the healthcare system is not the only answer."Certainly not the only answer. But if you buy the notion that there is some sort of compelling moral obligation to provide care to all Americans, it bothers me that in some places (like Scalpel's home, it would seem) there are no obstacles to care for the poor and there is comprehensive care for all, yet in other localities, like mine, the uninsured are SOL and on their own. The availability of such a fundamental need should not vary by location. I've no problem with using states as laboratories to come up with innovative solutions for intractable problems. But this doesn't require a whole lot of clever thinking -- we know the problem and the solution. I don't care who administers it, but there should be a national standard and national funding. Realistically, this means a federal program. Also, from my politically liberal point of view, I am suspicious of local control, since local programs are more easily subverted and nullified. Reminds me of when Newt tried to break up welfare into "block grants" for the states to disburse as they saw fit. But that is another topic.

Boy, that's a lot for now. More to come as I have time to think & digest. Thanks again to all who have read and contributed.

19 comments:

"As long as we are willing to pay for it -- through payroll, or taxes, or premiums -- there is no reason we cannot continue to enjoy the current quality of care that exists."

Well, there is already a differenial in quality amongst hospitals, at least from the patient's perspective. As ERC said, she would "rather have hubby seen by one of the best, than go to another hospital and not get as good healthcare."

The trouble is that not everyone can go to UAB or the Mayo Clinic or Johns Hopkins et al. So if we're nationalizing healthcare, many of us are going to have to settle for less prestigious arrangements.

Rationing is inevitable when one cuts the pie into 300 million pieces.

The right to life is a fundamental right; therefore health care necessary to sustain life should be considered a fundamental need inseparable from the right to live.

Sorry, but I don’t see the logical extension that you see here. The right to life has always meant that another person is not allowed to take your life. In other words, murder is a crime. The right to life doesn’t inherently mean that other people must actively sustain your life. Of course, one can define “right to life” that way but that is not the inevitable logical extension.

In a way, the whole idea of defining human rights in the negative only, i.e. what other people are forbidden from doing to you, as opposed to in the positive (what other people are obligated to do for you), is uniquely American. Of course, we can all decide that we as a society should provide healthcare for all, and I am not necessarily opposed to the idea. But chalking up the distinction between a right and an entitlement to semantics doesn’t sit well with me.

first of all, thank you for your thoughtful discussion about this. i really appreciate it. it's very emotional, and i've said things on previous entries that were probably tactless towards certain people.

it's a really emotional issue for me right now because my girlfriend has stage four hodgkins with liver involvement at the moment, and of course does not have insurance. and it's enough for me to lose faith completely when i start to get the preception people in the oncologist's office (and the oncologist in particular) aren't maybe giving it their all in my mind. and of course, when i get this perception, it's hard not to immediately interpret it as something that's happening because of their resentment towards the fact that they know they're not getting paid.

the thing that i find most offensive, the thing that indicates to me that there are a lot of people who do basically think you're SOL and should just get out of their face when you're sick and uninsured... is the complete lack of interest or even thought towards experimenting with any type of national healthcare system down the road. i mean, i think a lot of people really genuinely believe that Single Payor would be a disaster (not on political grounds but on common sense grounds), and yet, what would be in the way of agreeing to set up a certain agreed upon system... and if it gets going and it's clear that it's crap, pivot to option B... or put it on hold and think it over again.

people against universal healthcare (especially those in DC) really don't give off the impression that something like this would ever even enter their beautiful minds.

"i start to get the preception people in the oncologist's office (and the oncologist in particular) aren't maybe giving it their all in my mind. and of course, when i get this perception, it's hard not to immediately interpret it as something that's happening because of their resentment towards the fact that they know they're not getting paid."

In all human interactions, if someone is willing and able to pay more, they generally get better service. Why should healthcare be any different?

Wouldn't it bother you to not get paid for your work?

Many of us are hesitant to embrace a(nother) national health system because we are intimately aware of the pittance paid by Medicare and Medicaid for our services, the difficulties we face in complying with their endless regulations, and the difficulties many patients face in receiving care through those programs. Why would we expect any other federal universal coverage program to be any different?

I always assumed that a "right to life" *also* included a right to basic life-saving measures.

I’m no historian, but I do believe that the rights to life, liberty, and property in the Bill of Rights and the Declaration of Independence derive from John Locke’s “natural rights”. A quick google search for John Locke brings up the following quote “The state of nature has a law of nature to govern it, which obliges everyone: and reason which is that law, teaches all mankind who will but consult it, that being all equal and independent, no one ought to harm another in his life, health, liberty or possessions...”

It is very much a stretch in my mind to think that John Locke and those after him had in mind a right to life-saving measures. Who would be responsible for delivering those measures? How would this right be enforced? As Thomas Hobbes said, ‘Covenants, without the sword, are but words and of no strength to secure a man at all.’ This is why the American Bill of Rights was created, to put serious muscle into protecting said rights.

There have been countries that declared “the right to health” for their citizens. Soviet Union was one of them. It was actually in the Soviet criminal code that a physician would be held criminally liable if he/she did not deliver health measures. I don’t know how the law was enforced and I don’t know if it’s on the books any longer. Basically it meant that the State (the Party) could call up a physician in the middle of the night and say: ‘Be ready in 5 minutes, there is a black Marusya coming to pick you up, comrade Stalin just threw up.’

i actually completely agree with you. if i were in the shoes of a doctor who knew a patient wasn't paying their bills, and that was directly effecting my pocketbook, it would be hard not to have at least a minimal amount of resentment-- despite how well i liked the person, wanted to treat them, and felt sympathetic towards their financial predicament.

what i was saying was that i resent that this is the case in the first place. it just shouldn't be this way, period. believe me, it's enough to handle cancer in the first place, without having to feel self-conscious about the fact that doctors and their staff feel like you're imposing on them unduly.

in the case of my girlfriend, she's worked all her adult life hard, she's smart, she's good hearted, she's humble, she gives way more than she asks for, and she got hodgkins.

my problem is, what part of that equation says that she deserves to be treated as a second class citizen when she's trying to beat her disease?

is is that she wasn't willing to dedicate 1/4th of her monthly income before the disease struck to paying for a sufficient personal insurance plan? when she was trying hard enough to afford paying rent and bills in the first place? or was it that she didn't try hard enough to find a job where there was health insurance, despite that she's been at the point, multiple times, where she didn't have the financial luxury to sit back and wait for that, because she had to find a job immediately?

and what makes all the other people who have been in her situation and will in the future deserve it?

i'm saying that as of right now, to call what this country has in terms of health care 'ideal' is what, in my mind, someone would say who hasn't had to go through something like what my girlfriend is going through right now.

and with regards to preventative health care being a bonus to universal healthcare, she had all the classic symptoms of hodgkins for a year or more before the lump above her collar bone became so large that she found it. sweating, severe itching, fatigue, etc.

i'd really like to think if she had had health insurance, a doctor's visit or routine xray would have prevented it from going to stage four.

is that a supposition that opponents of universal health care would protest?

anon -Hm. Loosely interpretated, would the refusal to provide life-saving treatment amount to someone harming the person? even if the someone constitutes "the state" or whatever?

Also, blahblah, the era in which both Locke and Jefferson wrote was completely different from the era that we live in. Why assume a basic right to [life saving] medical treatment when it just didn't exist at that time?

I don't think that a right to healthcare springs full grown from the right to life, liberty, and property. I think that there are certain things that cannot be based on how good a capitalist you are.

But first, there are lots of things that should be based on how good a capitalist you are. You should be able to eat in nice restaurants. You should be able to drive nice cars and have cool computers. You should get to go on vacations. If you are a good capitalist, that is, you do a job that allows you to acquire money within the confines of our legal system, then you deserve those things.

I don't care how hard you work; I don't care how socially valuable your work is; I don't care how much training it took to do the work you do. If you are a good capitalist, it is moral that you should enjoy the fruits of capitalism.

However, being a good capitalist should not entitle you to vote twice. You should not be allowed to break the law. You should not be allowed to live longer.

Why? Well, I can stomach preachers, teachers, social workers, etc. driver less nice cars than lawyers, doctors, and corporate executives. But I cannot stomach them being allowed to suffer from sickness longer. I think its wrong.

We aren't doing very well in any of these three areas. Attorneys provide pro bono assistance to the indigent, but not nearly enough to make our justice system equal. Equal access to politicians, please? Frankly, medicine is definitely the closest.

This isn't a legal argument. It is a moral one. Just because we believe that the wealthy--like me, btw--deserve to have nicer things, does not mean that we have to believe the wealthy deserve better medicine, protection under the law, or political representation.

being a good capitalist should not entitle you to vote twice. You should not be allowed to break the law. You should not be allowed to live longer

You should not be allowed to live longer? Once you turn 70 (65, anyone?), and your tax return shows 500K (100K, anyone?) of income, let’s just kill you off. It must feel great, jimii, to be as moral as you are.

I don't necessarily agree with a blanket statement like that. As I have said before, just because a technology is available doesn't mean everyone is equally entitled to it.

Those who try to claim the moral high ground never seem to want to discuss the concept of lines being drawn, but in a single payer system rest assured that lines will be drawn, budgets will be kept, and care will be denied.

I concede it's an oversimplification. Poor people will always die earlier, from a variety of other causes, of course. And I've already said that I would be OK with a system which was tiered so some degree, so long as everybody was guaranteed some basic level of benefits.

And remember that of the plans being discussed for universal health, "Single Payor" is just one and not necessarily my favorite. Wyden's plan seems to have some distinct advantages and also guarantees universal coverage, without rationing.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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